HomeMy Public PortalAbout5516-5518-5520-5522 SULTANA AVE_Sewer__ 1 �
WORKERS'COMPENSATIO ARATION 0D APPLICATION FOR PERMIT
... • 1 CECE 808
8089 D 80)
I hereby affirm that 1 have a certificate of consent to self SEWER-SEWA E DISPOSAL
Insure or a certificate of Workers'Compensation Insurance,or ,
a certified copy thereof c 3800} b COUNTY OF LOS ANGEL .BUILDING AND SAFETY
follcy No•4�jh4f�pant ' _
' Ceytfred copy Is hereby furnish FOR APPLICANT,TO FILL IN CONNECTION DATA
�// pis lLDlnG O r arwrloN -f-1� BKITH
Cerhfiad copy B filed with the coup y 1 Ing I ctlon ADD...a L, y( ePCR
departme t n� r ( p (/� [{{ /Z LOCALITY L MANHOLE REIER¢NCV LOWER
Date Applicant %lCeOA�S I ri G'/LO�J NEAREBT TYPE OF LENGTH PROM
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST Y r L M L TO I L
COMPENSATION INSURANCE ,I PC xD
OVNERIIA CO IMI NO JOB NO }
MAIL d
(That Section need r be Completed If the Work orrOlVed AOOR¢aa TRUNK PERMIT NO ROAD I¢RMIT NO O
by the permit u for one hundred dollars (S100) or less) VA 9 AFIID.vIT wAA,.w AAvUn REEORD I..TR N DATA U
CI� TEL NO
1 certify that In the performance of the work for which this LEGA
permit ts Issued I shell not employ any person In any manner DESCRIPTION LOY No HWY OR ST WIDENING O
so as to become subject to the Workers' Compensation Laws L)
BLOCK TRACT STATE ENCROACHMENT W
Date Applicant NO OI BLESS r¢RMIT NO
NOTICE TO APPLICANT If, after making this Cenifleate of SIZE of LOT Now ON LOT Z
'Exemption you should become subject to the Workers' USE OF CHARGES
Compensation provisions of the Lobar Code, you must forth BUILDINGS
with comply with such provisions or this permit shall be CONTRACTOR CONNECTION CHARGE F¢e
deemed revoked
LICENSED CONTRACTORS DECLARATION ADDRESS REIMPUR9¢MENY IEE
I hereby affirm that I am licensed under provisions of Chapter _ 79,7 I RIcT No Aour B. MAP ;;;ii
LICKS 9 (commencing with Section 7000) of Division 3 of the BUIR errr ¢L NoA; .
nese and Professions Code, and my license Is in full force and 9Twra O CL ��Y" �D
4f—
effect BE NLIC
NO DESCRIPTION OF WORK F¢¢
License Number Llc Class •.nuc�..a....N..TIn. TO FATE ' VALIDATION
..ITIS r r... •ToR G
Contractor Date ITS ND/OR DRAInrIELDFINAL
"OUSE •` CONNECTING TO
O TEU:OSAL.Y.T.H BY
v
I em exempt from the licensing requwements as 1 am a HRCT ADDITIONAL BLDG OR
licensed architect or a registered professional engineer .r...... ....R
acting in my professional capacity (Section 7051, BusRZ.TNFLOI..ArwG. . RAINVIALD
mess and Professions Code) ....r..1 o ..HDL.
ALTAR w.Iw IR OR w HOUSE
SKWER OR DI
P.I.L f
Lic or Reg No Date
HOME OWNER BUILDER DECLARATION
1 hereby affirm that I em exempt from the Contractor s OWNER'S Permit g
License Law for the following reason (Section 7031 5, Busl AUTHORIZATION TOTAL FEE $oc2 3 8
news and Professions Code _
1 as owner of the property will do the work and the Twwcru 1.HC....E I..w.ov.Di:.So... a �No o Ano
TOT.. Owuc ..w. nl ` A J '/fl
structure u not intended or offered for sale (Section SIGNED THIS�O Ar OF V . A w19,P16
7044, Business and Professions Code) owH.R oR
own.we Aea B .I. s
CONSTRUCTION LENDING AGENCY ADD....
I hereby affirm that there u a construction pagency 1022-8o
for the performance of the work for which this
his p permit Is
issued(Sec 3097 Civ C)
Lender s Name
i Lender's Address
1 I certify that 1 have read this application and state that the '
above Information is correct I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers, '
and hereby authorize representatives of this County to enter
upon the above mentioned property for Inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Slgneture of Permittee Date